Provider Demographics
NPI:1245516178
Name:SPECIALIZAED MEDICAL, INC
Entity type:Organization
Organization Name:SPECIALIZAED MEDICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-720-3824
Mailing Address - Street 1:PO BOX 21715
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-0715
Mailing Address - Country:US
Mailing Address - Phone:612-720-3824
Mailing Address - Fax:888-546-6978
Practice Address - Street 1:19679 CALGARY TRL
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024-1488
Practice Address - Country:US
Practice Address - Phone:612-720-3824
Practice Address - Fax:888-546-6978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN335G00000X, 332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
No335G00000XSuppliersMedical Foods Supplier